Deep infiltrating endometriosis is defined as endometrial tissue infiltrating the peritoneum by more than 5 mm. A definitive diagnosis requires laparoscopy to visually inspect the pelvis. Treatment options include laparoscopically assisted surgery and abdominal incisions depending on the location of lesions. Pain associated with deep infiltrating endometriosis results from peripheral nerve stimulation and sensitization due to endometriosis-associated inflammation.

1. DEEP INFILTRATING
ENDOMETRIOSIS
 OLEH : Rika Effendy
 Pembimbing : Dr. dr. Hanom Husni Syam, SpOG(K), M Kes.

2. Deep Infiltrating Endometriosis:
D
I
E
Surgery
Medical Treatment
Definition and pathogenesis
Diagnosis

3. Deep endometriosis was defined arbitrarily as endometriosis infiltrating the peritoneum by >5 mm(6). Microscopically, this definition included bothadenomyosis externa
and deeper typical lesions (described as type I). Typical lesions are multifocal and surgically less demanding. Nodules of adenomyosis externa (type II and type III
lesions) are generally unique at the level of the rectum, rectosigmoid, sigmoid, or vesicouterine fold.

5. Endometriosis: The implantation theory
Sampson JA AJOG (1927)
Glands
Stroma

6. Endometriosis:
The implantation
theory
OMA
SUP DIE
Three phenotypes
- SUP: Peritoneal superficial endometriosis
- OMA: Ovarian endometrioma
- DIE: Deep infiltrating endometriosis

7. Diagnosis
Compared to
laparoscopy, magnetic
resonance imaging (MRI)
has limited value as a
diagnostic tool for
endometriosis
Strength of evidence A
ESHRE Guideline
Human Reproduction Vol.20, No.10 , 2005
Magnetic resonance imaging (MRI)

8. Diagnosis
A definitive diagnosis of
endometriosis, visual
inspection of the pelvis
at laparoscopy is the
gold standard
investigation
Strength of evidence B
RCOG Guideline No. 24 October 2006
Laparoscopy

11. Endometriosis associated pelvic pain:
Peripheral nerve stimulation and sensitization via endometriosis-associated
inflammation
McKinnon et al., Trends Endocrinol Metab (2015)

12. Segmentalresectionfor
colorectal
endometriosis:arethere
alternatives?Gynecol
ObstetFertil2012.Feb
 Outcome CR resection incomplete when assessing QOL,infertility and
recurrence
 Associated with significant morbidity
 Alternatives shaving,discoid resection or superficial resection ? equivalen
efficacy with decreased morbidity
 Insufficient data to clarify indications for segmental resection and
alternatives
 Randomised trials needed-BUT by whom?
PJMMHWENDO2014

13. Bowelresectionfor
deependometriosis:
asystematicreview
CDeCiccioet
al.(2010)BritJObstet
Gynaecol
 Objectives: To review systematically segmental
bowel resections for endometriosis for
indications,outcomes and complications according
to level of resection and volume of nodule.
 Data collection did not allow a meaningful meta-
analysis
 34 articles describing 1889 bowel resections-level
of bowel resection and size of lesion poorly reported
 Pain relief was reported as excellent for the first
year after surgery
 Complication rate was comparable with that of
bowel resection for indications other than
endometriosis
PJMMHWENDO2014

14. Indicationsfor
segmental
bowelresection
 Indication was variable
 Most decisions made pre-operatively based on
investigations including TVUS,TRUS and MRI scanning
 Size of nodule >2cm or >3 cm.and degree of muscularis
involvement or percentage of circumference involved
 In review of 1248 procedures, decision made 14% pre-op
and 86% intra-op.Wide variation between
authors,Redwine and Wright(11.5%) to 92% Ribeiro et al.
PJMMHWENDO2014
De Cicco,2010

15. Recommendation
forendocrine
pharmacotherapy
ofEndometriosis

16. Current
Treatmentof
Endometriosis

17. Conclusion
 Presence of endometrial tissue outside of the uterus and infiltrating the
peritoneum by >5 mm
 A definitive diagnosis of endometriosis, visual inspection of the pelvis
at laparoscopy
 Peripheral nerve stimulation and sensitization via endometriosis-
associated inflammation
 Treatment for DIE  laparoscopically Assisted Surgery and Abdominal
incision base on location

18. Thankyou